Improve efficiency with automated diagnostics, paperless patient records

Issue: October 2000

With computers taking over the business offices and reducing manual tasks more than ever before, optometry practices are no exception. Practitioners are becoming increasingly pressured for time – usually time to fit more patients into an already hectic schedule – and, as a result, interest in office automation has soared.

With refraction expending such a large amount of the doctor’s time, companies are refining autorefractors in the hope that one day they will be the sole basis for the glasses or contact lens prescription. Similarly, computerized lensmeters assist in efficient prescribing, and more and more practices are opting for a paperless office through computerized medical record-keeping systems.

“What I like about automated equipment is that you can teach relatively unskilled staff how to use the instrumentation,” said Walter West, OD, in private group practice in Brentwood, Tenn. “The outcome of the information from that instrumentation isn’t negatively impacted by their skill level, because the subjective variations are taken out of it. There are distinctive advantages to being able to improve the patient flow – one of the big issues is being able to increase capacity and get more patients through per clinic hour.”

Autorefractors: worth the cost?

With the expense of autorefractors, some practitioners wonder whether the machines are worth the cost. In most cases, optometrists say that the prescription computed by an autorefractor needs to be double-checked and refined prior to prescribing lenses for a patient.

“Autorefractors can definitely allow a practitioner to see more people in less time,” said Jerome Legerton, OD, MBA, FAAO, president of the EPIC Group. “But I’m not aware of any practitioner that would prescribe off of one. In that case, it only becomes the starting point for refraction. So there’s a real question as to whether spending the money and having a technician do it for you is actually any more efficient than doing a retinoscopy. The threshold to cross is the point that the results are accepted for use as the prescription, or a refinement procedure that actually takes less time than a traditional subjective refraction.”

However, many companies offer an autorefractor/keratometer combination instrument, which more than justifies the expense, said Dr. West. “It would be worth the cost for nothing more than time efficiency, but the other thing is you get two things done at once,” he said. “Most of the autorefractors on the market do autorefraction and keratometry at the same time, so you get two measurements in less time than it takes to do either one of those two manual procedures. So it’s more efficient from that standpoint, and I think it’s more consistent than retinoscopy.”

Current models

Topcon has a line of autorefractors, including the KR8000 PA, which is a tri-function autorefractor/keratometer that also offers topography. The space-saving instrument, which also features a rotary prism for more accurate measurements, also has an automated tracking mechanism, said Steve Hamilton, product manager for Topcon.

“You don’t have to use the joystick,” said Mr. Hamilton. “Once you get this machine in the ballpark, and you can see the eye on the display monitor, it will auto-track and auto-fire. This machine increases office efficiency and space efficiency in the office because one instrument is collecting all of that pre-test information.”

The current model from Zeiss Humphrey Systems (Dublin, Calif.), the Humphrey Acuitus Automatic Refractor/Keratometer model 5015, boasts 30 measurements per second and auto-acquisition, which means the instrument automatically acquires refraction and keratometric data upon alignment.

The Tomey RC3000 Autorefractor-Keratometer suggests contact lens base curve values and offers measurements in 0.07 seconds in the refractor mode and 0.17 seconds in the keratometer mode. It also offers a stand-by mode, designed to reduce power consumption, which activates automatically after 3 minutes.

Nikon’s Speedy-K autorefractor/keratometer also has an automatic shutoff feature after a 3-minute period has passed. The instrument employs the tangential method, which measures four peripheral points in the 25-degree direction simultaneously to save time. Data for 100 patients may be stored in the Speedy-K memory.

Case history part of refraction

Many elements of a personal level go into refraction, said Dr. Legerton, which makes sole reliance on autorefractors more difficult. “Optometrists, in particular, appreciate refining refraction and prescribing based on some elements of a case history,” he said. “In a subjective refraction, it is not only what selection a patient makes in comparison, but how they answer. In some cases you might add a quarter diopter or cut back a quarter diopter, and that’s tied into this analog information that is derived from actually doing the refraction. I believe that is essential given the patient comfort expectations in developed countries that have offered sophisticated vision care for some time.

“On the other hand, 80% of the world’s population, in third-world and emerging countries, don’t have access to an optometrist,” he said. “If I were providing vision care on a World Health Organization basis, I would prescribe off of an autorefractor every day.”

Computerized lensmeters

The main selling point of automatic lensmeters is their ease of use among untrained staff, the practitioners said. “The number-one internal problem facing optometry — and this has been true for the last 20 or so years — is the quality of ancillary personnel,” said Dr. Legerton. “We are not able to be high payers and we’ve got full employment today. So we work hard to retain highly skilled individuals. Yet the knowledge required in an ophthalmic or optometric technician is so high, we’re hiring new people all the time. To teach just lensometry is challenging.”

The new computerized lensmeters take care of that problem, said Dr. West. “It’s much easier to train a new employee how to use it, so the learning curve is much more abbreviated than it would be on the manual lensmeters that have existed for years,” he said.

Topcon’s CL100 model has very simple progressive lens measurement functions, said Mr. Hamilton. “It uses new targeting and auto sensing technology, and it makes a quick and simple method of measurement for even inexperienced users,” he said. “It interfaces with other equipment, including our autorefractor. So this device can actually send data over to the autorefractor, and then you gather your pre-test information with the autorefractor, press the print button and accumulate all of the data on one printout.”

Tomey’s TL-3000 Autolensmeter automatically detects multifocal lenses when in auto mode, and readings are automatically held when the lens is properly aligned. Alignment assistance guides the user to correctly position the lens. Lens positioning is important, said Dr. Legerton, and different lensmeters vary when advising the technician to center the lens.

“Some instruments are more forgiving than others – they will send error messages when the lens is not centered,” he said. “But teaching centration is, by physical observation, easier than teaching manual lensometry. Some instruments take repetitive measures and averages while the lens is staged, and then you mitigate the standard error of the measurement.”

The Zeiss Humphrey Lens Analyzer models 350 and 360 with Spexan, designed for simple operation even for the untrained staff member, features an icon-based interface to guide the operator through the neutralization process. They automatically calculate the monocular and binocular spectacle pupillary distance without centering the lens.

Computerized medical records

As computers become faster and more compact and boast a greater amount of memory than ever before, many modern optometric practices are looking to make their offices paperless to both create a more efficient office as well as save space. While several companies are creating software to access patient charts at the touch of a button, there are mixed emotions among practitioners about computerized medical record-keeping.

“I’m a real believer in it,” said Dr. Legerton. “I don’t think it’s a pipe dream; it’s the ultimate. It was a pipe dream in 1988, when I was lecturing on the paperless office, because the storage capacity of computers was so limited. But now, there are multiple gigabyte and CD read-only type memories, which is essential in record-keeping so that a record can’t be altered. One of the greatest errors in optometric offices today are errors in transposition, or re-writing. Every time you write the prescription, you have a chance for another error. That’s just one simple example of the value of electronic records.”

Dr. Legerton said that since there are only a limited number of responses a patient is likely to give to the doctor’s questioning, those answers can quickly and easily be entered as a code into the system, saving a great deal of time. “When I would ask about someone’s distance vision, I began to write down the individual responses. I found that there are only about 12 different responses that people can give,” he said. “So when you ask the patient the question, you can then hit 1 or 2 digits for the answer.

“Digitizing case history is easy,” he said. “Then, when you’re taking other clinical findings such as refraction and phorometry and biomicroscopy, nearly everything can be keyed in. Every lens type could be bar coded on a sheet of paper as either high index, antireflective coating, scratch resistant and tints, and the person in the dispensary can just take the bar code wand, go to the sheet and have every item that enters the dispensary stored electronically.”

Todd Hostetter, COMT, CRA, FCLSA, division manager for IFA Systems, LLC (Milford, Mass.) said that letter writing is a major advantage of computerized medical record-keeping. “Documentation for letter writing is important,” he said. “Doctors can cover 95% of their dictation or even create more letters than they’re accustomed to straight out of the electronic medical records. Their communication with referring doctors becomes better and much more efficient.”

Mr. Hostetter said that IFA System’s Patient Manager interfaces with other diagnostic instruments in the office and can be customized to an individual practice. “We can actually specify different kinds of exams, for example, a tech exam, an exam for low vision, a contact lens exam or an exam for a diabetic screening,” he said. “There is virtually no keyboarding. We have Smart Screens, which have little buttons that you click on to write to the exam form. We program and customize the button to the particular individual.”

Opis-CPR Computerized Patient Records (South Dennis, Mass.) capitalizes on the frequent patient responses by supplying thousands of pre-written fields, with full editing capability, in the software system. Similarly, the system’s Auto Letters feature enables the user to select a patient name from the database, and it automatically crafts a professional letter using exam findings from the patient’s record. Another feature that keeps the record paper-free is ExamDraw, in which the user creates an electronic document drawing with a mouse or pen-mouse.

Medicare coding

Computerized medical record-keeping also facilitates exam coding, said Mr. Hostetter. “It will tell practitioners exactly what they’ve recorded and will appropriately code the level of service so they can bill properly for that exam,” he said. “Otherwise, they have to look through their notes – and they get paid today on what they document, not necessarily what they do. So it ties in very nicely with electronic medical records.”

Some insurers prefer electronic coding for their own ease of use as well, said Dr. Legerton. “If you can use a code for a diagnosis and a code for treatment — especially if we agree on common definitions – then with five digits everyone's on the same page,” he said. “Your payers have done it for their own interest, too. If you can’t electronically bill on some programs, you’re off the program. So if that information has to be submitted digitally, why not put it in at chair side just one time?”

MaximEyes’ (First Insight, Hillsboro, Ore.) Electronic Claims feature helps expedite the coding process. This enables the practitioner to connect with more than 500 payers and most states directly, featuring a five-step process for electronic claims transmission. Downloadable clearinghouse reports and bills help track what has been paid and when. MaximEyes can also be linked to Web site builder optometry.net and the e-commerce engine paradEyes.com.

Paperless records: foolproof?

Many practitioners hesitate to go paperless for fear of patient records being lost on a computer’s hard drive, and many still opt to keep a hard copy back-up. The growth of the electronic back-up systems and relative inexpense of today’s computers and those on the horizon make that a nearly unfounded fear, said Dr. Legerton.

“The day will come when archiving paper is not important because of the reliability of back-up systems and the amount of data that can be stored on just one CD-ROM,” he said. “Computers have become so inexpensive that you could have a back-up computer such as a notebook in case the system goes down. A CD costs so little that you could burn a CD at the end of every day.”

However, some are more reluctant to part with a hard-copy record-keeping system. “I’ve had a lot of people tell me why they think it’s neat and why they think it’s the wave of the future, but I haven’t had anybody yet tell me how it saves time or makes me more money,” said Dr. West. “Until they develop a more efficient method of data entry and can show me where I’m going to end up after making the capital investment in new equipment, how I’ll be more profitable at the end of the month or how it can help provide the patient with a better level of care, I’m not interested.”

For Your Information:

Walter West, OD, is in private group practice. He may be reached at 205 Ward Circle, Brentwood, TN 37027; (615) 373-0080; fax: (615) 373-2848. Dr. West has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Jerome Legerton, OD, MBA, FAAO, is president of the EPIC Group and is a member of the Primary Care Optometry News Editorial Board. He may be reached at (619) 758-9140; e-mail: jerryL@visx.com. Dr. Legerton has no direct financial interest in any of the products mentioned, nor is he a paid consultant for any companies mentioned.

Steve Hamilton is the product manager for Topcon. He may be reached at 37 West Century Rd., Paramus, NJ 07652; (800) 223-1130, ext. 257; fax: (201) 634-1365.

Todd Hostetter, COMT, CRA, FCLSA, is division manager for IFA Systems, LLC. He may be reached at 113 Cedar St., Suite S6, Milford, MA 01757; (800) 619-4448; fax: (717) 653-6453.

The KR8000 PA autorefractor/keratometer and the CL100 lensmeter are available from Topcon America Corporation, 37 West Century Road, Paramus, NJ 07652; (201) 261-9450; (800) 223-1130; fax: (201) 634-1365.

The Acuitus Automatic Refractor/Keratometer model 5015 and the Lens Analyzer models 350 and 360 with Spexan are available from Zeiss Humphrey Systems, 5160 Hacienda Dr., Dublin, CA 94568; (877) 486-7473; fax: (925) 557-4217.

The RC3000 autorefractor-keratometer and TL-3000 autolensmeter are available from Tomey Corporation USA, 300 Second Ave., Waltham, MA 02451; (781) 890-1515; (800) 358-6639; fax: (781) 290-5885.

The Speedy-K autorefractor/keratometer is available from Nikon Inc., 1300 Walt Whitman Road, Melville, NY 11747-3012; (516) 547-8610; fax: (800) 645-6602.

The Patient Manager is available from IFA Systems, LLC, 113 Cedar St., Suite S6, Milford, MA 01757; (800) 619-4448; fax: (717) 653-6453.

The Opis-CPR Computerized Patient Records system is available from Opis Software, P.O. Box 1412, South Dennis, MA 02660-1412; (508) 760-3937; (800) 272-OPIS; fax: (508) 398-4471.

MaximEyes is available from First Insight, 3305 Northwest Aloclek Dr., Suite 200, Hillsboro, OR 97124; (503) 533-4555; (800) 920-1940; fax: (503) 533-8484.